Healthcare Provider Details

I. General information

NPI: 1609454867
Provider Name (Legal Business Name): ELITE DENTAL CARE EADS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3159 HIGHWAY 64 STE 100
EADS TN
38028-3322
US

IV. Provider business mailing address

2066 US HIGHWAY 45 BYP S
TRENTON TN
38382-3507
US

V. Phone/Fax

Practice location:
  • Phone: 901-465-2382
  • Fax:
Mailing address:
  • Phone: 731-855-1053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CLINT BUCHANAN
Title or Position: OWNER
Credential: DDS
Phone: 731-855-1053